What to do for lumbosacral (lower back) pain caused by playing pickleball in incorrect running shoes?

Management of Lumbosacral Pain from Pickleball and Improper Footwear

Start immediately with nonpharmacologic therapy—specifically supervised exercise therapy combined with heat application—while avoiding bed rest and continuing modified activity. 1

Immediate First Steps

Stop wearing the wrong running shoes immediately and obtain proper court shoes with lateral support, as pickleball involves rapid directional changes that running shoes are not designed to handle. 2, 3 The sport's quick pivoting and lateral movements place unique demands on footwear that differ fundamentally from running's linear motion patterns. 3

Initial Self-Care (First 2-4 Weeks)

• Apply superficial heat to the lumbosacral region, which provides moderate pain relief within 5 days and improved disability at 4 days compared to placebo. 1
• Combine heat with exercise for greater pain relief than exercise alone at 7 days. 1
• Stay active and avoid bed rest, as bed rest leads to deconditioning and worsens symptoms. 1 This is critical—the pain improves with lying down because it's mechanical/load-dependent, but prolonged rest will make recovery slower. 1
• Use acetaminophen or NSAIDs for pain control if needed, with NSAIDs being first-line pharmacologic therapy showing superior pain relief. 1, 4

Exercise Therapy: The Cornerstone of Treatment

Begin supervised, individualized exercise within the first 2-4 weeks, as this is the most effective intervention with moderate-quality evidence showing 10-point improvements on a 100-point pain scale. 5, 1

Specific Exercise Approaches (Choose Based on Availability)

• Motor control exercises (MCE) targeting coordination, control, and strength of spinal-supporting muscles show the strongest evidence, with sustained benefits and pain reductions of 7-12 points on a 100-point scale. 5, 1
• Individualized programs incorporating stretching and strengthening produce the best outcomes in meta-regression analyses. 1
• Yoga (particularly Iyengar or Viniyoga styles) demonstrates moderate superiority over self-care with sustained benefits at 26 weeks. 5, 1
• Tai chi has moderate-quality evidence for pain improvement at 3 and 6 months. 5, 1

Timeline for Exercise

For acute low back pain (<4 weeks), supervised exercise is not yet proven effective, but spinal manipulation shows small to moderate short-term benefits. 5 However, given your pain is activity-related from pickleball, starting gentle exercise early (after 2 weeks) is reasonable. 5

Additional Effective Nonpharmacologic Options

• Spinal manipulation by appropriately trained providers (chiropractor or physician trained in manipulation) provides small to moderate short-term benefits. 5, 1
• Massage therapy shows moderate effectiveness for chronic low back pain. 5, 1
• Acupuncture is moderately effective if symptoms persist beyond 4-8 weeks. 5, 1

Pharmacologic Management (If Nonpharmacologic Insufficient)

• NSAIDs first-line with moderate-quality evidence for superior pain relief. 1
• Duloxetine second-line if NSAIDs inadequate, particularly if any neuropathic pain components exist. 1
• Tramadol as an alternative second-line option. 1
• Avoid systemic corticosteroids, as they are not more effective than placebo for low back pain. 5

Critical Pitfalls to Avoid

Do not pursue interventional procedures such as epidural injections, facet joint injections, or radiofrequency ablation for mechanical axial spine pain—these have strong recommendations against their use and do not improve morbidity, mortality, or quality of life. 1

Do not routinely obtain imaging unless red flags are present (progressive neurological deficits, cauda equina syndrome, suspected infection, or malignancy). 1

Do not use lumbar braces or supports, as they show no clear benefits and may increase risk of lower back pain. 6, 1

Do not use TENS, as it shows no benefit compared to sham TENS. 1

Return to Pickleball

Gradual return to play is appropriate once you can perform sport-specific movements without significant pain, typically 4-6 weeks with proper treatment. 4 The case report of a gluteus maximus tear in a pickleball player showed return to play at 4 weeks with conservative management. 4

Sport-Specific Considerations

• Ensure proper footwear with lateral support before returning. 2, 3
• Most pickleball lower extremity injuries occur in patients over 60 from sudden directional changes and twisting mechanisms. 3
• Warm up adequately and consider sport-specific conditioning to prevent re-injury. 2

When to Refer

Refer to multidisciplinary pain management if pain persists despite optimized nonpharmacologic and pharmacologic therapy over 3-6 months. 1

Immediate specialist consultation required for red flags: progressive neurological deficits, cauda equina syndrome, suspected infection, or malignancy. 1

Expected Outcomes

Expect small to moderate improvements (approximately 10 points on a 100-point scale) with nonpharmacologic therapies, with effects on function generally smaller than effects on pain. 1 The key is consistent adherence to exercise therapy and activity modification while avoiding the pitfalls of bed rest and unnecessary interventions. 5, 1